Geriatric Guidelines Include Chiropractic, Sort of

In March of 1998, the board of directors of the American Geriatric Society approved clinical practice guidelines for chronic pain in older persons.¹ And while these guidelines tend to be focused on pain management from a medical/pharmacological approach, they make specific references to chiropractic and other forms of alternative care as important components in pain treatment:

"Pharmacologic therapy is most effective when combined with nonpharmacologic strategies to optimize pain management."^2,3

The guidelines contain a section on the "nonpharmacologic strategies for pain management in older persons."

"Nonpharmacologic approaches, used alone or in combination with appropriate pharmacologic strategies, should be an integral part of care plans for most chronic pain patients. Nonpharmacologic pain management strategies encompass a broad range of treatments and physical modalities. Education programs, acupuncture, transcutaneous nerve stimulation, chiropractic,⁴ heat, cold, massage, relaxation, and distraction techniques have each been helpful for some patients. Moreover, these strategies carry few adverse effects other than cost. Many patients use these approaches, not always with the advice of their primary health care provider."

Specific recommendations for the nonpharmacological approach include:

I. "All patients with diminished quality of life as a result of chronic pain are candidates for nonpharmacologic pain management strategies."

III. "Nonpharmacologic interventions can be used alone or in combination with pharmacologic strategies for chronic pain management."

VIII. "Other nonpharmacologic therapies may be helpful for some patients with chronic pain. Chiropractic, acupuncture, or transcutaneous nerve stimulation may be helpful for some patients, but they are expensive and have not been shown to have greater benefit than placebo controls in the management of chronic pain. These interventions should be provided only by professionals."

Chiropractors will vigorously take exception to the contention that chiropractic is more expensive and of no greater benefit than placebo. Clearly, the board of directors of the American Geriatric Society haven't been reading the cost-effectiveness studies comparing chiropractic and medical care for back pain! And the placebo comments will have chiropractors pulling out their collective hair.

Even though the focus of American Geriatric Society is still on medicating patients, the guidelines do put the geriatric medical physicians on notice that chiropractic and other forms of alternative care "should be an integral part of care plans for most chronic pain patients."

Perhaps the American Geriatric Society is catching on that patients are seeking out alternative practitioners over primary physicians by a nearly 2-1 margin.⁵

But questions remain:

How do you combine chiropractic (the nondrug-oriented care) with drug therapy for older patients with chronic pain? How should the chiropractic profession integrate into geriatric care to serve this ever-growing segment of our population?

References

1. The management of chronic pain in older persons. J Am Geriatr Soc 1998;46:635-651.
2. Jacox A, Carr DB, Payne R et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No. 94-0592. Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Service, Public Health Service, March 1994.
3. Ferrell BR. Patient education and nondrug interventions. In: Ferrell BR, Ferrell BA, eds. Pain in the Elderly. Seattle: IASP Press. 1996 pp35-44.
4. Lavsky-Shulan M, Wallace RB, Kohout FJ et al. Prevalence and functional correlates of low back pain in the elderly: The Iowa 65+ Rural Health Study. J Am Geriatr Soc 1985; 33:23-28.
5. In 1997, the increase in annual visits to alternative practitioners grew from 427 million to 629 million, nearly double the number of visits to all primary care physicians (386 million). Eisenberg DM, Davis RB, Ettner SL et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998;280:1569-75.